National ADAP Technical Assistance Meeting July 16, 2009

1. National ADAP Technical Assistance MeetingJuly 16, 2009 National Policy Landscape and Updates Julie Scofield and Laura Hanen

2. Overview of Presentation • Landscape • Obama Administration • 111th Congress • Policy Updates • National HIV/AIDS Strategy • Ryan White Program • Health Reform • FY2010 Appropriations Status

3. Obama Administration Landscape • President Obama • Included increases for care and prevention in tight FY2010 budget • Issued HIV Testing Day video statement • Maintained White House AIDS office • Taking steps to remove the HIV entry ban • Proposed moving away from abstinence-only education to comprehensive sex education • Prioritized health reform including a focus on prevention

4. Obama Administration Landscape • Jeff Crowley, National AIDS Coordinator and Senior Disability Advisor • Member of the Domestic Policy Council • On Nancy Ann DeParle’s health reform team • Charged with developing the National HIV/AIDS Strategy • In process of hiring staff and detailees • Will have more staff than other DPC staff • $1.4 million secured by AIDS community for ONAC • Eric Goosby, Global AIDS Coordinator

5. Obama Administration Landscape • HHS Secretary Kathleen Sebelius • Awaiting leadership at CMS, NIH, and SAMHSA • Staffing up at HHS still occurring • Policy based on science not ideology • HIV Testing Day video • HRSA Administrator Mary Wakefield • Breath of fresh air • Experience as a grantee • Experience on the Hill • CDC Director Tom Frieden • Interest in HIV, advocate of testing, condom social marketing

6. Kathleen Sebelius Secretary, HHS Dora Hughes Counselor for Health Policy Bill Corr Deputy Secretary Paul Dioguardi Director Intergovernmental Affairs Margaret Hamberg CommissionerFood & Drug Administration Josh Sharfstein Deputy Commissioner Howard Koh Assistant Secretary for Health Charlene Frizzera Acting AdministratorCenters of Medicare and Medicaid Services Regina Benjamin Nominee for Surgeon General Mary Wakefield AdministratorHealth Resources and Services Administration Cindy Mann AdministratorCenter for Medicaid and State Operations Christopher Bates Director Office of HIV/AIDS Policy and Executive Director,President’s Advisory Council on HIV/AIDS Raynard Kington Acting DirectorNational Institutesof Health Tom Frieden DirectorCenters for Disease Control and Prevention Eric Broderick Acting AdministratorSubstance Abuse and Mental Health Services.Administration Garth Graham DirectorOffice of Minority Health

7. HRSA HIV/AIDS Bureau Deborah Parham HopsonAssociate Administrator Laura Cheever Deputy Associate Administrator Ruth RomanDirector Office of Program Support Michael Evanson Acting DirectorDivision of Community Based Programs Faye MalitzDirectorDivision of Science and Policy Doug MorganDirectorDivision of Service Systems Steve YoungDirectorDivision of Training and Technical Assistance

8. 111th Congress Landscape • Very partisan, while support for HIV and hepatitis is bi-partisan • House Speaker Nancy Pelosi (D-CA) and Energy and Commerce Committee Chair Henry Waxman (D-CA) • Long-time advocates for AIDS issues • Leadership role in health reform • Fewer Republican moderate supporters • House: Castle (DE), Bono, Mack (CA), Biggert (IL), Frelinghuysen (NJ), Kirk (IL), King (NY), Ros-Lehtinen (FL), Smith (NJ) • Senate: Collins (ME) and Snowe (ME) • House and Senate Labor-HHS-Education Appropriations Subcommittee minority members are very conservative • Given the Stimulus experience, a lot of basic education is needed on HIV and STDs

9. Policy Updates

10. National HIV/AIDS Strategy • Three goals for the NHAS • Reducing HIV incidence • Increasing access to care • Reducing HIV-related health disparities • Federal interagency committee will develop • Broad input will be sought using campaign model • 10 regional meetings • Website, community meetings, house parties • PACHA to have a feedback and monitoring role • Congress provided $1.4 million for development

11. Ryan White Program - Context Action must be taken – law “sunsets” in September ‘09 Pursuing an extension with “tweaks” Many competing national priorities Little new information to inform 2009 process Client level data will be inaccurate & incomplete All HIV reporting systems nationwide are not mature Results of unobligated balances/penalties just being experienced First Part B Supplemental awards not yet made Health reform outcome will inform next full reauthorization

12. Ryan White Extension – Administration Community and Congress waiting for the Administration’s official position HRSA has shared policy recommendations with HHS HHS yet to make recommendations to National AIDS Coordinator Mary Wakefield – game changer Willing to go to Hill and answer questions Already a more collaborative process between Congress and Administration With HRSA part of the process Congressional intent of any changes should be clear

13. Ryan White Extension – Congress Senate Health, Education, Labor and Pensions (HELP) Committee and House Energy and Commerce Committee Democrats asking questions/getting answers from HRSA; assessing committee members needs; and assessing community consensus document Senate Republicans have request in to GAO on several RW issues; support extension in theory to maintain “important changes” made in 2006 Same staff working on health reform and the time line is slipping

14. Ryan White Extension – AIDS Community Most organizations working through the Federal AIDS Policy Partnership Ryan White Working Group Co-chaired by Ann Lefert, NASTAD and Bill McColl, AIDS Action Community consensus document supported by over 270 organizations. Key agreements: Extension of three years Very few changes to minimize opposition Allowed minority positions Agreed to work together on next full reauthorization process

15. Ryan White Extension – AIDS Community Meeting with Hill offices to create sense of urgency for action At request of House staff, providing legislative language of majority positions If bill is last minute, what concession to Dr. Coburn will the states have to make? Putting pressure on Administration to release official position Grassroots putting pressure on Congress 12 weeks and counting before sunset!

16. Issues for ADAP Consensus fixes affecting ADAP ADAP rebate as program income Unobligated balances expanded to 5% and removal of penalties Maintaining hold harmless Continuing protection for former code states

17. Health Reform - Context HIV/AIDS community fighting for meaningful health reform to: Expand access to care and treatment Expand access to prevention services Enhance and support public health Coalitions include: HIV Health Care Access Working Group Association of State and Territorial Health Officials Affiliate Council and the Trust for America’s Health (TFAH) Health Disparities Coalition

18. Health Reform - Context Highlights of community position Expanded access to Medicaid for all low-income people and Early Treatment for HIV Act A public insurance option with sufficient subsidies to ensure access to meaningful care for people with HIV/AIDS Strengthen Medicare by eliminating the “donut hole” and other cost sharing barriers; in the short term allow ADAP expenses to count towards TrOOP Address the HIV/AIDS provider workforce crisis A prevention and public health investment fund with guaranteed funding for state public health

19. Congressional Process U.S. Senate HELP Committee passed bill after 11 days of markup Finance Committee released options and still negotiating a bipartisan product Two bills to be merged before going to Senate floor likely in September U.S. House of Representatives The three committees released Tri-Committee bill yesterday Committees holding mark ups starting today Speaker Pelosi committed to passing bill on House floor before August recess

20. HELP Committee Bill“Affordable Health Choices Act” Play or pay for employers Mandate for individuals to purchase coverage with hardship waiver Subsidies up to 500% of FPL Establishes a government run “public plan” option Creates “Gateway” (state exchange) that certifies private insurance plans Insurance market reforms

21. HELP Committee Bill “Affordable Health Choices Act” Invests in health care workforce Expands Medicaid to 150% of FPL New insurance regulations to eliminate exclusions for pre-existing conditions, limit premium rating variability, limit insurance company profits, etc. “Medical Advisory Council” would decide what are considered “essential” health care benefits Prevention and Public Health Investment Fund that increases from $2 to $10 billion 340B provisions to expand eligible entities and ensure availability of pricing

22. Senate Finance Committee Options Play or pay for employers Tax credits for mandated individual coverage up to 300% FPL, fine for non-compliance An insurance exchange for private plans Non-profit consumer owned and oriented plan Consumer protections regardless of health status

23. Senate Finance Committee Options Medicare eligibility at 55 and no 2-year wait Phased-in Medicaid for all citizens below 100% of FPL, children and pregnant women up to 133% Market reforms in small and non-group markets Four benefit categories – Bronze, Silver, Gold, and Platinum Prevention in the context of Medicare, Medicaid and workplace wellness

24. House Tri-Committee Draft Individual mandate to purchase or pay penalty Employer pay or play Health insurance exchange for public and private plans Public health insurance option Guaranteed coverage and insurance market reforms Basic benefits package recommend by independent advisory committee Sliding scale credits up to 400% FPL Caps on annual out-of-pocket spending

25. House Tri-Committee Draft Expands Medicaid to 133% FPL, phased in, federally financed, and increases reimbursement to primary care providers, ETHA sunsets January 2013 Improves Medicare including filling donut hole over time and ADAP expenses counting towards TrOOP Investments in health care workforce Public Health Investment Fund which grows from $4.7 billion in FY2010 to $8.8 billion in FY2014 Prevention and Wellness Trust starting at $2.4 billion in FY2010 and rising to $3.5 billion in FY2014 Includes funding for state and local public health infrastructure

26. Issues for ADAP Potential for many current Ryan White clients to be covered by Medicaid or in private or public insurance exchange Savings for ADAPs if donut hole is closed over time Savings for ADAPs if ADAP expenses count toward TrOOP Benefit coordination by ADAP will be a major role for programs – presents challenges for structure of ADAPs A likely pay-for will be increasing the Medicaid rebate which will effect 340B pricing

27. FY2010 HIV Federal Funding

28. FY2010 Appropriations Status • President provided $54 million increase to Ryan White Program and $53 million increase to HIV prevention • President’s budget is key benchmark for Congress of same party • While not sufficient, HIV is doing well in tough funding environment • House subcommittee marked up last week providing similar increases for care and prevention • Removed ban on federal funding of syringe exchange • Eliminated funding for abstinence-only programs and redirected toward preventing teen pregnancy programs • Bill to be marked up by House full committee Friday and on House floor before August recess • Senate subcommittee scheduled to mark up next week, may slip • Bill not likely to be completed before beginning of fiscal year on October 1

29. Ryan White Program Funding PresidentHouse Subcommittee • Total: $2,267.4 m (+$54.0 m)$2,267.4 m (+$54.0 m) • Part A: $671.1 m (+$8.0 m)$679.1 m (+$16.0 m) • Part B Base: $418.8 m (+$10.0 m)$418.8 m (+$10.0 m) • ADAP: $835.0 m (+$20.0 m)$835.0 m (+$20.0 m) • Part C: $211.9 m (+$10.0 m)$206.8 m(+$5.0 m) • Part D: $76.9 m (0) $78.7 m (+$2.0 m) • AETCs: $38.4 m (+$4.0 m) $35.2 m (+$0.8 m) • Dental: $15.4 m (+$2.0 m)$13.8 m (+$0.36 m)